FROM INFECTION INDEPENDENT OF VISCERAL DISEASE.

19.-Psora-Scabies-Itch.

The itch makes its first appearance, usually, between the fingers, about the wrists, and upon the backs of the hands, in the form of minute vesicles, filled with a colorless, transparent fluid, intermixed with small papulæ, which latter likewise assume, in a short time, the vesicular character. The eruption is attended by intense itching, which is always increased by whatever elevates the temperature of the part. Frequent friction and scratching, to allay the itching, produce speedily an inflammation and rupture of the vesicles, by which means the disease is extended to the surrounding skin.

When the skin is very irritable, the vesicles of psora soon assume an opaque appearance, and are converted into true pustules, which sometimes attain a very considerable size. Hence, when the malady is of some standing, there may exist, at the same time, papulæ, vesicles, and pustules, of various dimensions, interspersed: a feature which, in connection with the excessive itching and irritation, will readily distinguish the itch from the other cutaneous affections.

In its commencement, the disease, in the majority of cases, is confined to the fingers, wrists, and hands; it may, however, extend to nearly every part of the body. In such cases, it is most severe and troublesome about the trunk, margins of the arm-pits, and in the flexures of the joints, in consequence of the warmth generated by the clothing, and the friction excited by the motions of the body and limbs. The papulæ, vesicles, and pustules often give rise to dark points, or dark-brown crusts, caused by the desiccation of the matter discharged by them. The pustules, sometimes, when neglected, coalesce, and when ruptured, form ulcerations, upon which dark-brown scabs are apt to form.

Psora, in the great majority of cases, is produced from the direct contact of the fluid matter of the vesicles, by the touch of an infected person, by the handling or wearing of his clothes, sleeping in the same bed, &c. It is increased in extent and virulence by a defect of personal cleanliness, from either a want of ablutions of the surface, sufficient in extent and frequency, or the necessary changes of linen. By a neglect of personal cleanliness, many suppose that the disease may be generated, independent of infection.

In its early stages, psora is entirely unconnected with any other disease. When, however, it occurs in children who are debilitated, or otherwise unhealthy, it not unfrequently gives rise to a troublesome impetiginous affection of the skin, which may continue long after the specific character of the psora has been destroyed (S. cachectica). It is said that it never, or at least very rarely, terminates spontaneously. When not subjected to a proper remedial treatment, it may continue during the lifetime of the patient, which it seldom, however, tends to shorten.

The disease presents itself under its most aggravated forms almost exclusively among the miserably poor; or among children who are

congregated in large numbers under one roof, fed on one and the same diet, and debarred from a sufficient amount of out-door exercise beyond the premises. It is met with more frequently in some countries and situations than in others. It is, in some degree, endemic in all cold and mountainous regions.

In many cases of psora, particularly when neglected, an insect is to be seen in or near the vesicles (scabies vermicularis, acarus vel sarcoptes scabiei). It is usually found beneath the cuticle, in a small spot close to a vesicle, to which it is connected by an irregular dotted line, that marks its burrowing course. If this spot be punctured, upon careful examination, the insect, somewhat resembling a cheese mite, may be detected, and abstracted upon the point of a needle. Of the existence of these insects there can be no reasonable doubt; but how far they are essential to the disease, and whether the latter is produced by them, are questions not so readily solved. The affirmative has been, recently, strongly maintained by several of the French and German physicians; while there are others who consider the insect as a mere parasite, in no way concerned in the production of the disease. The supposed cases in which the itch has been communicated by transferring the acarus to the skin of sound persons, have been ascribed alone to the virus adhering to the insect. This view, we feel disposed to adopt as the correct one. It is extremely difficult to reconcile the ease with which the disease is communicated by mere contact, with the notion that the transfer of one of the insects is necessary to its production, especially when we are told of the difficulty of extracting these from their burrows beneath the cuticle. It is said by Mouronval, Lugol, and Gras, that the disease cannot be communicated by inoculation with the fluid of the vesicle. This we believe to be an error. We knew the disease to be produced, in one case, by an individual who put on a pair of gloves that had been worn four months previously by a person affected with the itch, and which had lain in a drawer from that period.

It is supposed by some that itch may be communicated to man from the dog and other domestic animals. Several workmen at the Jardin des Plantes, of Paris, are said to have contracted the disease, by attending upon a diseased camel. (Andral, Cazenave.)

The disease may be communicated to infants and children at any period from birth to puberty. It generally occurs about four or five days subsequent to exposure to its contagion.

A great variety of external as well as internal remedies have been proposed for the cure of the itch. They have all, no doubt, frequently succeeded. In the ordinary forms of the disease, there is one to which all others are inferior in efficacy. We allude to sulphur, externally applied, either in the form of ointment or fumigation; with its internal use, in the form of the precipitated sulphur, mixed with milk or molasses. In the disease as it usually occurs in children, the ordinary unguentum sulphuris of the shops will answer every purpose; in more obstinate cases, the compound sulphur ointment of the United. States Pharmacopoeia may be employed. An ointment composed of one part carbonate of potassa, two of sulphur, and eight of lard, is pre-

ferred by many of the French practitioners. Whichever of these ointments is used, it should be well rubbed into the affected parts. night and morning, for the space of one week. By that time, or perhaps earlier, the disease, in slight cases, will be entirely cured. On ceasing the use of the ointment, the child should be immersed in a warm bath, and the entire surface of the body well washed with soap. In children of four or five years, and upwards, the common soft soap may be used, which, by some of the recent German physicians, is asserted to be of itself an excellent remedy in cases of inveterate itch. During the external employment of the sulphur, a portion of itfrom ten grains to half a drachm, according to the age of the childshould be given, night and morning, in milk or molasses. In plethoric or robust children, over two years of age, an equal portion of the bitartrite of potassa may be added. The diet of the patient should be perfectly plain and easy of digestion. After the cure is affected, no portion of the clothing or bedding that was in contact with the patient whilst he labored under the disease, should be used, until it has been thoroughly purified and well aired.

In many cases an ointment of the iodide of potassium, made by adding one drachm to one ounce of lard, will prove a very efficient remedy; we have used it with complete and prompt success in numerous instances. An ointment composed of half a drachm of sulphuret of lime, mixed with a little olive oil, and rubbed upon the palms of the hands, twice a day, for ten or fifteen minutes each time, will, it is said, prove, also, an efficient remedy. (Joy.)

The sulphurous water-bath has occasionally been employed; it is by no means so prompt and certain in its effects, as the sulphur vapor bath. The latter constitutes the principal remedy of Galès, and it has been strongly recommended by Horn, De Carro, Wallace, and other physicians who have employed it. In children of eight, ten, and twelve years of age, we occasionally meet with cases, in which from neglect, and personal uncleanliness, the disease has been allowed to spread over a considerable portion of the body, and in a form of considerable severity. To these cases, the sulphur vapor-bath is well adapted. The number of fumigations necessary will depend very much upon the character of the disease in each case, the degree of irritability of the skin, &c. When a proper apparatus can be procured, this should be invariably employed; if not, blankets may be saturated with the vapor of sulphur, by means of sulphur strewed upon burning coals, inclosed in a warming-pan; the patient being placed between the blankets, naked, and covered closely up to the throat.

A variety of other modes of treatment have been proposed, none, however, in the case of children, are equal in efficacy to those detailed. It is asserted by Pentzlin, that an ointment composed of one part of tar, and two parts of salt butter, melted together, with the addition, while fluid, of one part of carbonate of potassa, will remove the disease in seven days, if applied once every twenty-four hours.

The following ointments have been found in infants, occasionally very useful. We annex them, not because we prefer them to those

we have already given, but because cases may occur, in which, from a variety of circumstances, it may be useful to resort to one or other of them.

When the disease occurs in robust and plethoric children, attended by considerable irritation of the skin at the parts affected, the treatment should be commenced by emollient poultices, warm fomentations, and brisk purgation. Should the local symptoms be very considerable, or should any undue degree of local irritation or inflammation occur during the use of the sulphur or other ointments, the application of leeches, or even the drawing of a few ounces of blood from the arm, may become necessary.

If the child be debilitated, or labor under any other disease, the remedies adapted for the latter conditions should be combined with the treatment required for the removal of the former.

20.-Syphilitic Eruptions.

Infants are liable to become infected with syphilis, either before birth, during birth, or during lactation. Infants born of mothers who are laboring under the venereal disease may exhibit indications of syphilis at birth; or the disease may not appear for many days, weeks, or months subsequently. Syphilitic children are frequently born prematurely or dead, with the cuticle separated, or peeling off from different parts of their bodies, or in a state of gangrene. Abortion is a very frequent consequence of intra-uterine infection.

It is a curious circumstance, that a child born of parents apparently in perfect health, may be infected at birth or soon afterwards, with syphilis, contracted from one or other of the parents, but which had, to all appearances, been fully eradicated several years before marriage. In cases like these, where there exist so many powerful motives for concealment or deception, there must, of course, always remain considerable doubt as to the fact of the entire freedom from disease of the parents. We have, however, met with repeated instances, in which there was every reason to believe that such was actually the case; and a similar statement is made by Burns, Veggio, Maunsell, Dendy, and others. It is more than probable, however, that in some of the numerous cases recorded in the continental journals, of syphilitic children born of parents in whom no vestige of the disease existed, eruptions of the skin of a non-venereal character may have been mistaken for those of syphilis. How far confidence is to be placed in the statements made of the foetus being liable to infection, in consequence of the father being, or having been diseased, while the mother is, and always has been, perfectly healthy, we are not prepared to offer any positive opinion. We have certainly met with cases which seemed to establish

very fully the fact. Mr. Acton, surgeon to the Islington Dispensatory, England, adduces three cases, in which constitutional syphilis in the father was the cause of repeated abortions, and, subsequently, of infection of a foetus born at the full period-the mother remaining throughout wholly free from disease. He gives an abridged account of two other cases of secondary syphilis in men, whose wives were free from all disease, but had miscarried. Dr. Behrend (Journ. f. Kinderkrankheiten) states that the disease is most frequently imparted to the foetus by the father.

Professor Sigmund, of Vienna, basing his observations on the result of sixty-one cases, states that when the mother is syphilitic the child seldom escapes infection. The intensity of the disease in it being in proportion to its intensity in the mother, and the recency of her infection. Of Dr. Sigmund's sixty-one cases seven were born prematurely, of which eleven were born dead. Of the forty-four infants born at full time, four were born dead; of the forty-six born alive, four only lived to the end of three months.

Intra-uterine syphilis generally presents itself in the form of red, brown, or fawn-colored blotches, varying in size, and slightly raised above the level of the surrounding skin. From the surface of these blotches, a very slight moisture exudes, which, in parts exposed to the air, on drying, gives to them a scaly appearance, and at length forms thin scabs, of a dark yellow or brownish color, which reappear as often as they are detached. The eruption usually occurs first upon the lower extremities, buttocks, and loins, but subsequently extends to the rest of the body, as well as to the face. When the blotches appear about the verge of the anus, between the buttocks, and in the folds of the thighs and neck, the continual moisture and friction of the parts prevent the formation of crusts, but irregular tubercular swellings (condyloma) occur.

With the progress of the disease, the skin becomes throughout of a reddish-brown or fawn-color. The infant is, at the same time, feverish, fretful, and gradually wastes away; its voice becomes feeble and hoarse, and there is a constant discharge from the nostrils of a yellow, viscid mucus, which quickly dries about the external orifices; the nose becomes swollen, and perpendicular fissures occur in the lips, giving a very peculiar appearance to the mouth. The whole countenance assumes at length a wrinkled, dejected appearance, and the infant exhibits evident indications of suffering, from deep-seated pains in the cylindrical bones. It becomes more and more feeble and emaciated. Ulcerations present themselves upon various parts of the skin; the inside of the mouth and surface of the tongue are often covered with aphthæ, and the patient finally dies, in a state of extreme debility and excessive emaciation.

Such are the usual phenomena and progress of syphilitic eruptions, from intra-uterine infection. We have known infants born of diseased parents to present irregular ulcerations, or large vesications on different parts of the surface, filled with a yellow, turbid or dark-colored fluid, and which, upon rupturing, left ulcerations of the skin, that became